Conceptualizing suffering and pain - Philosophy, Ethics, and ...

An understanding of pain and suffering life experiences is proposed, ... related to that person's attachment to life and the world. Skiptomaincontent Advertisement SearchallBMCarticles Search DownloadPDF Research OpenAccess Published:29September2017 Conceptualizingsufferingandpain NoeliaBueno-Gómez  ORCID:orcid.org/0000-0001-8764-65491  Philosophy,Ethics,andHumanitiesinMedicine volume 12,Article number: 7(2017) Citethisarticle 50kAccesses 26Citations 30Altmetric Metricsdetails AbstractBackgroundThisarticleaimstocontributetoabetterconceptualizationofpainandsufferingbyprovidingnon-essentialandnon-naturalisticdefinitionsofbothphenomena.Contributionsofclassicalevidence-basedmedicine,thehumanisticturninmedicine,aswellasthephenomenologyandnarrativetheoriesofsufferingandpain,togetherwithcertainconceptionsofthepersonbeyondthem(themind-bodydichotomy,Cassel’sideaofpersonsas“intactbeings”)arecriticallydiscussedwithsuchpurpose.MethodsAphilosophicalmethodologyisused,basedonthereviewofexistentliteratureonthetopicandtheargumentationinfavorofwhatarefoundasbetterdefinitionsofsufferingandpain.ResultsPaincanbedescribedinneurologicaltermsbutcognitiveawareness,interpretation,behavioraldispositions,aswellasculturalandeducationalfactorshaveadecisiveinfluenceonpainperception.Sufferingisproposedtobedefinedasanunpleasantorevenanguishingexperience,severelyaffectingapersonatapsychophysicalandexistentiallevel.Painandsufferingareconsideredunpleasant.However,theprovideddefinitionsneitherincludetheideathatpainandsufferingcanattackandevendestroytheselfnortheideathattheycanconstructivelyexpandtheself;bothperspectivescanbeequallyusefulformanagingpainandsuffering,buttheyarenotdefiningfeaturesofthesame.Includingtheexistentialdimensioninthedefinitionofsufferinghighlightstherelevanceofsufferinginlifeanditseffectonone’sownattachmenttotheworld(includingpersonalmanagement,ortheculturalandsocialinfluenceswhichshapeit).Anunderstandingofpainandsufferinglifeexperiencesisproposed,meaningthattheyareconsideredaspectsofaperson’slife,andtheselfistheever-changingsumofthese(andother)experiences.ConclusionsTheprovideddefinitionswillbeusefultotheidentificationofpainandsuffering,tothediscussionofhowtorelievethem,andtoabetterunderstandingofhowtheyareexpressedandexperienced.Theylaythegroundworkforfurtherresearchinalltheseareas,withthetwofoldaimofa)avoidingepistemologicalmistakesandmoralinjustices,andb)highlightingthelimitationsofmedicineinthetreatmentofsufferingandpain. IntroductionThisarticleaimstocontributetoabetterconceptualizationofpainandsufferingbyprovidingnon-essentialandnon-naturalisticdefinitionsofbothphenomena.Suchdefinitionswillbeusefultotheidentificationofpainandsuffering,tothediscussionofhowtorelievethem,andtoabetterunderstandingofhowtheyareexpressedandexperienced.Theprovideddefinitionslaythegroundworkforfurtherresearchinalltheseareas,withtheaimofavoidingepistemologicalmistakesandmoralinjusticessuchastheexclusionofcertainexperiencesfromthedefinitionofsuffering.Definitionsarenotinconsequential,sincethewayinwhichwedefineconceptshasepistemological,ontologicalandpracticaldimensions.Classicalevidence-basedmedicineunderstandspainfromanaturalisticpointofview,andpersonsasbeingsaredividedintotwodifferententities:thebodyandthemind.Evenifthisperspectivehasledtogreatsuccessinthereliefofpain,certainproblemshaveremainedpartiallyorentirelyunresolvedand/orunexplained,forinstancetheplaceboeffect,chronicpainandnon-somaticpain.Moreover,classicalevidence-basedmedicinehasbeenincreasinglycriticizedfromthesecondhalfofthetwentiethcenturyonwards.Thispaperwillbeginbyexplainingtheconceptionsofpainandpersonusedbyevidence-basedclassicalmedicineandtheirCartesianroots,followedbyacriticaldiscussionofthecontributionsmadebythehumanisticturn(representedbyCassell),andfinally,thephenomenologyandnarrativeconceptionsoftheselfandtheperson.Analternativetothemind/bodydichotomyisassumed,consistingofanunderstandingofpersonsaspsychophysical,socioculturallysituatedbeings.Bothpainandsufferinghavebodily,psychologicalandsocioculturaldimensions.Pain(likepleasure)hasbeendefinedasaprocessresultingfromasomatosensoryperception,subsequentlypresentinthebrainasamentalimageandfollowedbyanunpleasantemotionaswellaschangesinthebody[1],butsuchaprocesscannotbedescribedexclusivelyintheseneurologicalterms.Cognitiveawareness[2],interpretation[3],behavioraldispositions[1],cultural[4]andeducationalfactors[1]influencetheperceptionofpain–forexample,paintoleranceorthepainthreshold.Footnote1Sufferingisproposedtobedefinedasanunpleasantorevenanguishingexperiencewhichseverelyaffectsapersonatapsychophysicalandanexistentiallevel.Evenwhensufferingisnotcausedbybiologicalorobservablecircumstances(likethepainassociatedwithtissuedamage),itisanembodiedexperiencewhichwecannotbutfeelintherhythmofourhearts,theclenchingofourstomachs,thesweatonourhands,our(in)abilitytosleep,orthepositionofourshoulders,justtoprovideafewexamples.Evenifsufferingdoesnotoriginatefromillnessorpain,itcanmakeusfeelillandcanevencauseustodevelopvariousailments.Paincanbeasourceofsuffering,butitisnottheonlyone.Socialproblemslikepoverty,socialexclusion,forcefulsocialinclusion(likepeerpressure),forceddisplacementanduprooting;existentialandpersonalproblemslikegriefandstress;conditionslikenausea,paresthesia,anon-painfulillness,anxietyorfearcanlikewisebeacauseofsuffering.Althoughpainandsufferingareunpleasant,theyarenotperseeitherdestructiveorconstructiveforceswhichteardownorbuilduptheself.Rather,theyarepartofaperson’slife,andtheselfistheresultofvariousexperiencesincludingpainandsuffering,whichhaveanexistentialdimensioninasmuchastheydependontheperson’sattitude,resourcesfortheirmanagement,aswellaschoicesandcommitmentsrelatedtothatperson’sattachmenttolifeandtheworld.Suchpersonaloptionsareinfluencedbysocial[5,6]andcultural[7,8]patterns.BackgroundThemind/bodydichotomyEvenifthe“problemofconsciousness”–“howconsciousnessarisesfrommatteror,morecautiously,howitisrelatedtomatter”[9]–isfarfromadefinitivesolution,thereisageneralizedagreementinliterature(particularlyinsociologyandthephilosophyofmedicine)regardingtheneedtoquestionthetraditionalCartesiandistinctionbetweenthebodyandmind[1,2,3].Küglerarguesfortheimpossibilityofconclusivelysolvingtheproblemofconsciousness,concludingthatphilosophymustcontinueworkingonthistopic.However,suchdifficulties(orevenimpossibilities)maybeduetothefactthatwecontinuetousetheclassicalconcepts:Wecannotresolvethisdualismifwestillthinkindualisticterms.Inordertoreframethemind/bodyproblem,weneedtothinkintermsof“embodyingthemind”and“mindingthebody.”Footnote2 Afterquestioningthemind/bodydualism,theconceptsofsufferingandpainneedtobereconsidered,evenifanewconceptualizationisindeeddifficult[10,11].Simplyput,itisnolongeracceptabletoconsiderpainonlyinphysicalandsufferingonlyinpsychologicalterms.TheCartesiandistinctionbetweenrescogitansandresextensaisthedrivingforcebehindthewholestructureofthinkinginandtheorganizationofmedicalsciencesandpsychology.Oncewequestionthisdistinction,weneedtoreconsiderthisstructureofthinkingandorganization,aswell.Questioningthedistinctionbetweenthebodyandmindisnotanewidea,despiteitspersistentprevalenceinWesternthought.Thematerialisticunderstandingofthemind(oneofthealternativestothemind/bodydichotomy)canbetracedasfarbackasthephilosophyofEpicurus.Footnote3Infact,thereexistsawholealternativeperspective,paralleltotheCartesianconceptionofthebodyandmind,developedbySpinozaandcontinuedbyNietzscheandtheAmericanpragmatists(particularlyWilliamJames),aspointedoutbyJohnson[10].ForDescartes,thebodyandmindaretwodifferentsubstanceswithadifferentontologicalstatus:Thebodyislikeamechanismthatexistsintimeandspace,itcanbemeasuredandsocanitsreactionsandprocesses;howeverthemindlacksthesespatialandtemporaldimensionsandcanexistwithoutacorrespondingbody.Accordingly,painissomethingwhichoccursinthebodyandwhichcanbedescribedintermsofvisible,physical,measurabledamage(forexample,tissuedamage).Inaperiodofincreasingimportanceofthenaturalsciences,theCartesianconceptualizationoftheresextensapresupposesaknowableworld,organizedaccordingtocertainnaturallaws[12].Itassumesthatitispossibleanddesirabletointerveneintheworldscientificallytofurthertheprogressofhumanity,whichincludesmedicine,inparticular.Byusingscientificmethodology,itisconsideredpossibletorepairabodyinthesamewayinwhichwecanrepairamachine(orananimal,inasmuchasDescartesconsidersanimalspartoftheresextensa).Descarteshimselfisengagedintheenterpriseofknowingtheworldinordertoturnhumansinto“maîtresetpossesseursdelanature”(“mastersandpossessorsofnature”)[12],proposingascientificmethodandusingittoimprovelivingconditions.Hetrustsinhumanreasontothepointofbelievingthatprogressinmedicinewillbeabletorelieveusofillnessandeventheweaknessassociatedwitholdage,thusshowingthefirstsignsofanattitudewhichreachesitspeakduringtheEnlightenmentanddeclines(inacertainsense)intwentiethcentury,whentherisksofscientificandtechnologicalinterventionstartedtobecomeapparent.TheCartesianperspectivedrovethedevelopmentofclinicalmedicineasanempiricalsciencebasedonevidence.However,forDescartes,itwasclearthatourstatesofmind(“esprits”intheoriginalFrench)dependonthe“dispositionoftheorgansofourbody”[12].Hence,medicineshouldcontributenotonlytothephysical,butalsotothespiritualandmentalwellbeing,andultimatelyresultin“wiser”humans,bothbecausemedicineisabletoprovidescientificknowledgeabouthumanbody(whichconstitutesacontributiontowisdom),andbecausemedicineprovidesusefulknowledgeaboutthebodywhichmightallowhumanstobefreeofillnessandweakness,thusenablingthemtodevelopandapplytheirintelligencetoincreasetheknowledgeofhumanity.Inshort,itisnottruethatthebodydoesnotmattertoDescartes,whowasarationalistbutnotanidealist,inthesensethathewasnotwillingtoriskhis“corporeal”existenceinordertodefendhisideas(hepreferredtoacceptrulesandlawsofhistimethatwereincompatiblewithhisownideasinordertoavoidimprisonmentandotherlegalconsequences,eventhoughhesupportedtheautonomyofreason).InthissenseCartesiandualismdoesnotimplyadismissalofthebody.Still,Descartesarguesfortheexistenceofanimmortalsoulwhichcanstandonitsown,withoutabody.HereinDamasioseesDescartes’“mistake”:intheideathatthemindcanexistorevenoperateindependentlyofthebody[1].Theconceptualizationofpainandsufferinginclassicalevidence-basedmedicinePainandsufferingcannotbetreatedexclusivelyinnaturalistic,scientificterms,atleastunderacertainviewofwhatscienceis.Medicinebecameascienceattheendoftheeighteenthcenturywiththeemergenceofclinical,evidence-basedmedicine.Inthecontextofsuchmedicine,sufferingandpainweredissociatedfromthecontextofatheodicy[13]andtobetreatedscientifically.Medicinestartedtobesystematicallyorganizedinclinicalenvironments,wherepatientscouldbeobservedandthesymptomsanddiseasescomparedanddescribedasneutrallyaspossible:AsexplainedbyFoucault,thephysicianmustdistancehimselffromthediseasedinordertolearnthetruthofthepathologicalfact[14].Diseaseandpainstartedtobeconsideredasbeingsituatedinbodies,sincebodiesandtheirprocessescametobeviewedinstandardized,universalizeableterms.Knowingthemedical,scientifictruthaboutpainrequiredbothabstractingthebodyfromtheperson,andthepathologicalfactfromallnormalbodilyfunctions.Thesedevelopmentsgaverisetothemodernproblematicapproachtodealingwithpainandsuffering.AccordingtoRey,“Atthedawnofthe19thcentury,physicianswerelookingforapuresignwhichwouldremovetheambiguitiesinherentinsymptoms.Theywishedtofindasign,themeaningofwhichwouldbeascertainasthatprovidedbythelesionfoundatdissection.However,theyweretobeconfrontednotonlywiththemultiplesignsfundamentaltopain,butalsobythatspecialexchangebetweenphysicianandpatientinwhich,whetherconsciouslyornot,thelatteradoptsadistinctiveattitudeinrelatingthedetailsofhispainfulsymptoms”[4].Thechallengeofmedicinebasedonobservation,objectivedescriptionofsymptomsanddiseasesFootnote4andexperimentallyproventreatmentsisdealingwithaphenomenonlikepain,whichmayormaynotcorrelatetophysicalsymptoms,whosereliefmayormaynotbeaffectedbytheadministrationofcertaindrugs,butnotalwaysandnottothesamedegree,andwhichisdefinitelymodulatedbycircumstanceswhicharedifficultorimpossibletomeasurescientifically,likeeducationalfactorsmoralorreligiousbeliefs,orpersonalattitudes.Painisnotakindofspring,andbodiesaremuchmorethanmeremechanisms,asphenomenologistshavestriventoshowinthe20thcentury.Abstractingthe“pathologicalfact”fromthebodyandthebodyfromthepersonfacilitatedanumberofimpressiveresults,treatmentsandmedicalprogress.However,itprovedtohaveitslimitationstoo.Painhasnotbeenatthecenterofmedicalinterestforthewholehistoryofmedicine.Ofcourse,pain,likesuffering,hasalwaysconcernedmedicine,buttreatingdiseasesinthesearchforhealingandaccumulatingthenecessaryknowledgeandexpertisetodosomoreeffectivelyinthefuturemaybeabetterdefinitionofthegeneralgoalofmedicineinalltimes[4].TheHippocraticmoralmaximof“primumnonnocere”hasfrequentlybeeninterpretedinthissense:Toinflictpain(iatrogenicpain)canbeconsidered“nonnocere”,thatis,notharmful,ifitisdonefortheultimategoalofcuringthepatient.Infact,theideathatgreaterpaincaneraselesserpainisalsoofHippocraticorigin.Thisprinciplewasparticularlyusedduringthenineteenthcenturybyphysicianswhobelievedthatpaincanbeusefulforthepurposeofhealing[15]:The“moxa”procedure(directmoxibustion)consistedofplacingaburningconeontheskinofapatientsufferingfromanailmentinordertoinfusethebodywithexternalenergyandstimulatethehealingprocess.Thepainresultingfromtheburnsorewasseenasessentialinswayingthebodytocombattheillnessorpainthepatientwassufferingfrominthefirstplace[4].Weareusuallywillingtoacceptcertainnuisancesorevenstrong,painfulsecondaryeffectsofmedicaltreatmentsifwetakethemtoenhancetherecoveryprocessorourqualityoflife.Morequestionableisthedamageinflictedinordertopreventamoreorlessprobablefuturedisease,andanentirelydifferentdiscussionconcernsthedamageinflictedinordertoimprovetheknowledgeofthediscipline.Inanycase,thefactofthematteristhatmedicaltreatmentsandhealingcan–andusuallydohave–painfulconsequences,andtheycancausesuffering.Theattitudeoftryingtoviewtheillsintheabstractinordertoknowthescientific“truth”ofthepathologicalfact,andtheempiricalmethodology,combinedwiththeideathathealingistheultimategoalofmedicine,werepreciselythefocusofthecriticismleveledagainstmedicine,thenewdemandsofpatientandprofessionalorganizations,aswellasthedisciplineofbioethicsbeginninginthe1960s.Allthesedemandsfora“morehuman”formofmedicineweredevelopedinasocialcontextofalarmabouttherisksoftechno-scientificprogressandthegeneralquestioningofauthorityonmanyfronts[16,17].Thiscriticismcametobeknownasthe“humanisticturn”anditemergedfromdifferentfronts:thehospicemovement[18],women’srightsmovementswhichadvocatedamoreactiveroleofwomeninchildbirth[19],Christianhumanisticcriticismagainstmedicalization[20],bioethicsanditscriticismofmedicalpaternalism[21],postmoderncriticismofmedicine[22],the“medicalhumanism”exemplifiedbyCassell’swork[3],andphenomenologicalaswellasnarrativeapproachestothepracticesofmedicineandtheexperiencesofthepatients,nottomentionthecontributionsofthehistory,philosophyandsociologyofmedicine,whichplacedanemphasisonitsfallibilityandlimitations,itshistoricalandsociologicaldimensions,and,lastbutnotleast,itsontologicalassumptions.Duetothisintense,yetunfinisheddebateandcriticism,clinicalmedicinehasbeguntochange,incorporatingmoreorlessparsimoniouslyanyoftherequiredreforms,whilesimultaneouslyincreasingitstechno-scientificdimension[23].Thesetheoreticalcriticalapproachesandtheparallelsocialactivismchallengedthemethods,goalsandconsequencesofmedicineindifferentways.Forexample,thehospicemovementisparticularlyrelevantconcerningtheaforementionedpredominanceofthe“healinggoal”insteadofthe“palliativegoal”ofmedicine.CicelySaundersandElisabethKübler-Rosspioneeredthismovementbyemphasizingthenecessityoftakingcareofpatientseveniftheirdiseasesareincurable.Displacingthegoalofhealingandsituating“care”initselfasafocusofhealthcareassistanceinvolvedincreasinginterestinthephenomenaofpainandsufferinginalltheirdimensions,aswellastheresearchdedicatedtoimprovingandimplementinganalgesia.Allthesecriticalapproachescoincideinademandfortheresituationoftheillpersoninmedicalcontexts.Thepatientshouldnotbeconsidereda“patient”anymore–apassivebeingpatientlywaitingfortreatmentsandmedicalexaminations.Themodernpatientexpectstonegotiatethemedicaldecisionsconcerningthem,becausemedicaldecisionsareneverstrictly“scientific”,butalsomoraland/orpolitical.Forexample,thedecisiontoacceptorrejectamedicaltreatmentinordertopreventapossiblediseasecannotbetaken“objectively”becausethisisnotapurelyobjectivedecision;itinvolvesissuesliketheevaluationofthesecondaryeffectsofthetreatment,thepersonalvaluesandprioritiesoftheaffectedperson,orhis/herabilitytoassumetherisk.Thescientificdimensionofthedecisioniscertainlyonlyoneamongmany.Sothechallengementionedpreviouslystillpersists,sincethephysicianisnowrequirednottomakeanabstractionoftheillperson,nottolookatthebodyasifitwereameremechanismtorepair,nottotakeintoaccountonlysomaticpain,butalsotoconsidernon-somaticpain,secondaryeffectsoftreatments,personalcircumstances,etc.Thissituationrequiresthereconceptualizationofpainandsuffering,andaseriousdebateaboutthegoalsofmedicineanditsroleinsociety.ResultsCassell’smedicalhumanismTheworkTheNatureofSufferingandtheGoalsofMedicinewasfirstpublishedin1982andhashadconsiderableinfluenceontheensuingdebateregardingthemedicalconceptualizationandmanagementofsufferingandpain.Infact,thisdebatehasnotyetended[24,25,26].Thisworkcanbeclassifiedamongthetheoreticalworksofthe“humanisticturn”inmedicine.Cassellcriticizesclinical,evidence-basedmedicine,itsdependenceonCartesiandualism,itsconceptualizationofpainandsuffering,itsmanagementofthem,aswellasthegoalsofmedicine.Hecriticizesexactlythosecharacteristicsofmedicinewhichtransformeditintoascienceinthefirstplace,thatis,theabstractionprocessesmentionedabove,thefactthat“doctorsaretrainedtofocusondiseasesandtokeeptheirsimilaritiesinmind,nottheirdifferences”,andthat“thediagnosticmethodsaredesignedtoseethesamethingineachcaseofadisease”[3].Forhim,theanachronisticdivisionbetweenbodyandnon-body,andthefocusonthecureofbodilydisease,leadsmedicinetodothingswhichcausethe“patientasaperson”tosuffer.Inotherwords,itnotonlytreatspaininadequately(understandingandtreatingitonlyinrelationtoitsmeasurable,observableandgeneralizablesigns,inthecontextofadisease)butitalsoproducessuffering,whichpersistsundiagnosedandunrelieved,asisthecaseintheterminalphaseofachronicdisease,whichisprogressivelylengthenedduetotheavailabilityofnewtreatments.Incontrast,Cassell’sconceptualizationofpainandsufferingemphasizestheirmeaningfuldimensionsandthenegativeconsequencesofabstractingthepainfromthepersoninpain.Ittakesintoconsiderationthatitisalwaysanindividualwhofeelspainorsuffering,andthatsuchexperiencesaremodeledandstronglydeterminedbypersonalassumptions,culturalpatterns,cognitiveactivitiesandevenreligiousbeliefs.Casselldefinespainnotonlyasasensation,butalso“asanexperienceembeddedinbeliefsaboutcausesanddiseasesandtheirconsequences”,andsufferingas“thestateofseveredistressassociatedwitheventsthatthreatentheintactnessofperson”.Bothpainandsufferingareconsideredtohavephysicalandpsychologicaldimensions,andinthissense,itistruethatCassellavoidstheclassicalassociationbetweenpainandbody,sufferingandmind.Footnote5Hisdefinitionofpainisinlinewiththedefinitionofferedatthebeginningofthisarticle:Painisaphenomenonwhichincludesbothnociception–“themechanisminvolvedinreceivingpainfulstimuli”–andthesubsequentattachmentofmeaningtosuchsensation.Herecognizestheuniversalityofnociception(“certainkindsofstimulielicitthesensoryresponseofnociceptionineveryculture,nowandforever”),butdoesnotconsiderpaintobethesameasnociception;forhim,painincludesthemeaningwhichthesubjectsascribetonociception,andsuchmeaningchangesfromculturetoculture,frompersontoperson.AccordingtoCassell,sufferingstartswhen“thesickpersonwillbelievethathisorherintactnessasapersonisindanger”.Sopaindoesnotnecessarilyentailsuffering,andsuffering(athreatagainstthe“intactnessofaperson”)canbecausedbyotherexperiences.Cassellproposesthatmedicineshouldbemoresensitivetothepersonandthemeaningsheorsheattributestohisorherpain/illness,andthatitshouldspecificallytreatsuffering,thusinvolvingparticular“subjectiveresources”like“feelings,intuition,andeventheinputoftheirsenses”inordertodealwiththesufferingofpatients.Otherauthorshavealsoemphasizedtheimportanceofparticularcapacitiessuchassensitivityandempathyinaphysician[27],developingan“affectivemodeofunderstanding”[25]inthecontextoftryingtohumanizemedicine.ButCassellalsothinksthatitispossibletodevelopamethodologywhichisabletoturnthesubjectivedimensionsofpainandsufferingintotransmissibleinformationthatphysicianscanuseinordertodevelopmoreholistictreatments(notonlydesignedtocureadisease,buttopalliatethesufferingoftheillperson).Inthismanner,thegoalsofmedicineoughttobereformulated.However,atleasttwoproblemsarisefromCassell’sconceptualizationofsuffering.Thefirstoneisthathisdefinitionofsufferingdependsonaquestionableunderstandingofthepersonanditistoorestrictive.Definingsufferingasathreatagainstthe“intactness”ofapersonentailsanassumptionofwhatan“intact”personis.Cassell’snormativedefinitionof“person”includesanumberofdimensionsliketheirperceivedfuture,personalityandcharacter,body,pastexperiencesandmemories,culturalbackground,behavior,relationswithothers,apoliticaldimensionandasecretlife[3].This“intact”personwouldhavedevelopedakindofequilibrium,orcoherenceandintegrity,amongallthesedimensions.Svenaeus[24]recognizesthisdifficultyinherenttoCassell’sproposal,theproblemofthinkingof“thepersonasakindofwhole”(orhowitispossibletoformulateakindofintegrityamongallthesedimensions),andoffersanalternative:understandinglifeasanarrativeand“stressingtheexperientialdimension,theholdingtogetherofstatesofconsciousnessmakinguptheself”.However,thenarrativeexplanationsofthecontinuityoftheselfandlifecanbecriticized,too.Althoughhumanbeingshavenarrativeexperiencesanddimensions,neithertheselvesnorlifearecompletelyanddefinitelyunifiedbyasinglenarrative.Thestorieswetellourselvesaboutourownexperiencesarecertainlyimportantresourceswhichweusetorelatetoourselves,todevelopourselves.Butsuchstoriesarenottheonlyresourceweuseforsuchpurposes.Forexample,wealsoengageindialoguewithourselves–theprocessofthinkinghasbeendefinedasakindofinnerdialogue[28]–andadialogueisnotastory.Moreover,suchinnerstoriesarealwayspluralistic:Theyinterpretourpastexperiencesinthelightofpresentinterestsorexperiences.Hencewedonottellourselvesthesamestoryaboutourpastduringourwholelife,simplybecauseourpastchangeseverydayaswegainnewexperienceswhichcaneasilymodifytheinterpretationsofpreviousexperiences,andweneed/wanttounderstandourpastdifferentlyaccordingtoourpresentandourprospects.Muchmoremalleableanduncertainareourstoriesaboutthefuture:Thefutureisunknownterritorythatslowlybecomespresentandthenpast,surprisingusagainandagain.Inparallel,lifeisnot“anarrative”,onesinglenarrativefrombirthtodeath[29].Differentversionsandinterpretationsaboutthelifeofapersonarecontinuouslywrittenfromdifferentpointsofview;thereisneveradefinitivehistory.Storiesaboutlifearealwaysfragmentary,partial,andtheycannotbetoldbutfromacertainperspective,dependingontheintendedemphasis.Theydonotguaranteethewholenessamongourseveraldimensions.Thus,thenarrativeexplanationofthe“wholeness”ofthepersondoesnotsupportCassell’sdefinitionof“person”.Indeed,suchadefinitionisanon-existentidealwhichincorporatestheideathatpersonsaretransparentforthemselves(theyknowthemselvescompletely),coherent,abletodesignakindofuniquepersonalpastandfuturestory,andwellbalanced.Thisdefinitionisfarfrombeinguptodateregardingthecontemporarytheoriesoftheself.AlbrechtWellmer[30]mentionstwocrucialcontributionsthatcontradictCassell’sdefinition.Freudianpsychoanalysischallengestheideaofanautonomoussubject:Humanbeingsdonotalwaysknowexactlyandcompletelywhattheywant,whattheydoorwhytheydoit,sincetheyareinfluencedbypsychological,socialandpower-relationsforces.Wittgensteinandthephilosophyoflanguagechallengetheideathatthesubjectsarethelastauthorsandjudgesofwhattheysay.Ourmeaningfulexpressionsarenotcompletelytransparenttoourselves.Moreover,postmoderntheoriesemphasizethecontradictionsamongvarioussocialrolesofthesameperson[31],ourirrationaldimension,ourcontingentnatureandthefactthatouractionsarenotpredictable(evenbyourselves).Apersonisneverfullycoherent,apersoncannotbe“intact”becausetouchingandbeingtouchedisintrinsictolife.Itmaystillbepossibletodefinesufferingasathreattowhatapersonconsiderstobehisintegrityatanygivenmoment.However,thisisanessentialdefinitionofsuffering,whichistoofar-reachingandcausesproblemswhentryingtodeterminetheboundariesofwhatisandisnotsuffering.Sufferingcanbeexperiencedindifferentways,notnecessarilyasathreatagainstone’sintegrity,asIwillshowlater.Sothisdefinitionisunabletoproperlyidentifywhatiscommontoallexperiencesofsuffering.Moreover,sufferinghasbeenseenandisoftenusedtoenhanceidentity(asinthecaseofthedeliberatesearchforsuffering,likeself-inflictingpain,andotherriskybehavior).ThisstandsindirectoppositiontoCassell’sdefinitionbecauseseekingoutsuffering(orusingnon-deliberatesuffering)isusedtobuildorenhanceidentity,toaffirmtheselfortoidentifyoneselfwithcertainvalueslikestrengthorcourage.ThesecondproblemofCassell’sdefinitionofsufferingisdiscussedbyBraude[25]:Theexperienceofsufferingmayhaveatrulysubjectiveelementthatcannotbeexplicitlycommunicatedthroughlanguageand“canandshouldneverultimatelybecomeanobject,medicalorotherwise”.Medicinecanpaymoreattentiontotheaforementionedsubjective,symbolicdimensionsofsufferingandpain,physicianscanbetrainedtobemoreempathetictowardsillpersonsandmoresensitivetotheirrealneeds.This“humanizedmedicine”providesabettermanagementofpainandsuffering,anditshouldreconsideritsultimategoals.However,thequestionremainswhethersufferingcanreallybetreatedsolelybymedicineandwithpurelyscientificmethods,consideringthisultimatelyincommunicabledimension,thefactthatnotallkindsofsufferingarerelatedtopainordisease,andtheexistentialdimensionofsuffering,whichincludespersonalchoicesrelatedtotheattachmentofthepersontolifeandtheworld.Medicinedoesindeedhaveitslimits.ThephenomenologicalapproachThephenomenologicalconceptualizationofsufferingandpainoffersanattractivealternativetodualistictheoriesandthemechanicalunderstandingofthebody.Footnote6Contrarytothescientificapproach,inwhichthebodyisseenfromathird-personperspective,phenomenologicalproposalsassumetheperspectiveoftheexperiencelivedbyasubject[32,33].Thisisakindoffirst-personperspectivethataimstobemeaningfulandrelevanttoothers.Agoodphenomenologicalapproachisnotmerelyasubjectivenarrativeofapersonalexperience,butisabletocapturecrucialelementsofsuchanexperiencewhichareusefulasmeaningfulresourcesforotherpersonstryingtounderstandsimilarexperiences.AverygoodexampleofsuchaperspectivecanbefoundinJean-LucNancy’stextL’Intrus,inwhichheaimstounderstandhisown“livedexperience”ofhearttransplantation,theassociatedseveremedicaltreatmentsandtheiracutesecondaryeffects,likelymphoma,philosophicallyandphenomenologically[34].Nancyconceptualizeshisexperiencenotmerelybytellinghisstory,butbyunderstandingittheoreticallythroughtheuseoftheconceptofthe“intrus”(intruder)andtheideaof“intrusion”tounderstandtheexperienceofreceivinganeworgan,itsrejectionbyhisimmunesystem,ofbeingtreated“medically”(measured,tested,monitored),andfinallythecancerandthesubsequenttreatments.Hisdescribedstrangenessofhimselfandhisexperienceofliminalityarefarfromunique,andhisreflectionaboutthemoralconsequencesoforgantransplantationandtheincreasingtechnologicalandscientificmedicaloptionsallraiseimportantpointsforfurtherdebate.Inshort,phenomenologyisnotmerelysubjective(althoughitincorporatespersonalexperience)andgoodphenomenologicalapproachesarepowerfulphilosophicaltools.Inasmuchastheyareabletoincorporatethefirst-personperspective,the“livedexperience”,theypossessahighpotentialforstudyingsufferingandpainfromaperspectivewhichisnotpurelyscientificormedicalinnature.Withnotionslike“embodiment”and“livingbody”–theEnglishtranslationoftheGermanterm“Leib”,inoppositiontothe“Körper”or“physicalbody”[11]–phenomenologistshavecontributedto“embodyingthemind”byemphasizingthecrucialroleofthebodyinhumanexperienceandbyassumingthatweexperiencetheworldthroughourlivingbodies[32].Thisassumptionentailsdifferentconsequencesfortheunderstandingofpainandsuffering,suchastheideathatifweareinpainorwesuffer,wefeelthisdispleasureinourbodies,thusinfluencingpartiallyortotallyhowweexperiencetheworld.Atransparent,silentorevenan“absent”body[32]canbecomepainfullypresent,soweexperiencetheworldfromthispainfulperspective.Footnote7 Phenomenologicalapproacheshavecontributedto“mindingthebody”too,asisthecasewiththephenomenologicalexplanationofthe“placeboeffect”,oneofthephenomenawhichchallengeclassicalexplanationsofmedicalscience.Frenkel[35]formulatesthischallengeasfollows:“Howcouldaprivatesubjectiveexpectancyassociatedwithtakingaplacebopillevermanifestasanobservable,publicchangeinthephysiologicbody?”Theplaceboeffectparticularlychallengesthemind/bodydistinctionandtheconsiderationofthebodyasamere“measurableobject.”TheexplanationofferedbyFrenkelisconvincing:Thebodyitselfisabletorespondmeaningfullytoademandingsituation,since“wehaveasentientbody,capableofrespondingtotheworldwithouthavingtoinvokeanyreflexiveactivity.”Itisevenpossibletogoonestepfurther:Ifweconceiveapersonasapsycho-physicalwhole,itisnotimplausibletothinkofthebodyreactinginmeaningfulways,that“apatientperceivesaffordancesofhealinginaparticularsituationandhisbodythusrespondstothesolicitationmadeuponitinthesamewaythatourunreflectivemotoractivityunfoldsintheworld.”Cultural,socialandpsychologicalfactorsarebelievedtoaffecttheaffordances(solicitationsofresponseforasubjectinaparticularsituation)ofhealing.Asalreadymentioned,Svenaeus[24]hascombinedphenomenologicaltendencieswithnarrativeconceptionsofpersonalidentityinordertoconceptualizepainandsuffering.Heputstogetherdifferentdefinitionsofsufferingprovidedbyotherauthorsinanattempttoencapsulate“thewholeofsuffering.”However,unitingthesedifferentapproachestosufferingdoesnotguaranteeagooddefinitionofsuffering,Instead,itguaranteesagoodoverviewofthestudiesorconceptualizationsofsuffering.Agooddefinitionshouldbegeneralenoughtoincludeallinstancesofsuffering.Thisdoesnotmeanthatparticulardescriptionsofcasesofsufferingarenotusefulormeaningfultoothersufferers,scientistsandsimplypersonsinterestedinunderstandthephenomenonofsuffering.Toputitinotherwords,thealienationoftheselfdescribedbyNancycancaptureoneessentialdimensionofonekindofsuffering,butitdoesnotdefineallkindsofsuffering.Definitionsofsufferingasathreatagainstan“intactperson”,asanalienationoftheself,asan“alienatedmood”or“unhomelikebeingintheworld”[33]expressdifferentexperiencesofsuffering,butthesearenotuniversaldescriptions,sotheyarenotgooddefinitions.AsKleinmanstates,“Itisimportanttoavoidessentializing,naturalizing,orsentimentalizingsuffering.Thereisnosinglewaytosuffer;thereisnotimelessorspacelessuniversalshapetosuffering.”[7].Losingtheselforfindingtheself?Asstatedbefore,itisstillachallengeformedicinetodealwiththesesubjective,unmeasurabledimensionsofsufferingandpain–and,moreover,theirpossible“unshareability”[6],althoughtherehavebeencrucialcontributionsliketheGateControlTheory,whichhasbeendecisiveinincludingboththephysiologicalandthepsychologicaldimensionsofpainasintrinsicpartsofthephenomenon.Still,painandsufferingdonotonlyconcernmedicine,butalsothesocialsciencesandhumanities,whichcontributesubstantiallytotheclarificationoftheircultural,socialandcognitivedimensions.Ifweattachimportancetothesedimensionsintheexperiencesofpainandsuffering,thenweneedtorecognizetherelevantrolewhichsaiddisciplinescanplayinmakingsenseofthemaswellasintheprovisionofresourcestorelievesuffering.Thistiesbacktothepreviousstatementofmedicinehavingitslimits:Therearetypesanddimensionsofsufferingwhosemanagementdoesnotconcernmedicine(oratleast,notexclusively).Forinstance,wecannotmanagesocialproblemsthatcausesocialsuffering,likepoverty,withmedicalresources.Butasstatedabove,thisdoesnotmeanthatmedicinecannotimproveitsmanagementofpainandsuffering:Onthecontrary,effortstodosoarealreadybeingmade,eventhoughacompleterevolutionwillrequiretrulyovercomingtheclassicalmind/bodydichotomy.Footnote8Areal,coherentassumptionofthepersonasapsychophysicalinsteadofadualisticbeingdemandsnotonlypartialreformsindealingwithsufferingandpain,butatotalparadigmshiftinthesenseofKuhn[36].Footnote9Inthemeantime,interdisciplinaryapproachesarebeingputintopractice;forexample,thetreatmentofchronicpaininthelongtermnowincorporatesconductisttherapiestomanageitsemotionalandcognitiveconsequences[37,38],orthetreatmentofnon-somaticpain(forexample,fibromyalgia)isnowsupportedbypsychotherapy[39].Thealienation(oreven“loss”)oftheselforthe“unhomelikebeingintheworld”canundoubtedlybeconsequencesorexpressionsofsuffering.KathyCharmaz[40]describesthe“lossoftheself”inchronicallyillpersonsandcontributestotheunderstandingofsufferingasnotlimitedtoamere“physicaldiscomfort.”Inhisrecent,posthumousnovelParis-Austerlitz,thewriterRafaelChirbesdescribesthelastphaseofaman’smortalillnessinthefollowingwords:“Rather,Ihadtheimpressionthatthemanlyingtherewastingawaybecameastrangerinbothmyeyesandhisown–someoneunknowntome,ofcourse,butalsotohimself,andsoMichelhimselfexpressedittomeondayswhenheexperiencedamomentoflucidity.[...]Michelwasbeingextinguished,fadingjustthesameaseachdayofmyvisit,thedimlightofthewinterafternoonwasfadingintheframeofthehospitalwindow.”Footnote10[41].LikeNancy,Michelcannotrecognizehimselfanymore,andneithercanhisfriend.ForSvenaeus,sufferingalienatesusfromourownbody,fromourengagementsintheworldwithothers,andfromourlifevalues[24].“Alienating”means“makingalien”,thussufferingisfoundtobeequivalenttothefeelingofbeingstrangerstoourselves,toothers,ortofittingintotheworldinanstrangeway–anditcanimpedeusinlivingtheliveswewanted.Thealienationoftheworldcanalsobecategorizedas“unhomelike”inawaysimilartoArendt’sconcept:“Unhomelikebeingintheworld”meansthatweexistinanuncomfortableway,inastrange,uneasyenvironmentwherewecannotrestorfindourplace[42].Thesevariouscontributionstounderstandingdifferentexperiencesofsufferinghavenotnecessarilybeenproposedasessentialdefinitionsofsuffering.Forexample,Charmaz’sworkassumesaclearlysituatedperspective;sheanalyzes“afundamentalformofsuffering”ofchronicallyillpersonsinAmericainthe1980s[40]However,theredoesexistariskintakingsuchdescriptionsofsufferingasuniversal,essentialdefinitions,sincedoingsomayhaveundesirableepistemologicalandmoralconsequences.Theideaofan“alienatedself”presupposestheideaofakindof“authenticself”withan“authenticlifestory”.Sufferingcanalienateusfromourpreviousconcernsandcanevendisplaceusintoastateofliminality,wherewedonotfeelathomeintheworldorinourbodiesasweonceusedto.However,asstatedpreviously,thesearenotdefinitiveconsequencesofsuffering,andpersonsarenotstatic,unchangeablebeings.Alongsidethepossible“lossoftheself”existsthepossibilityof“reconstructingtheself”(wewerenotour“definitiveself”before“losingourselves”duetosufferingandwecannotrecoversomethinglikea“definitiveself”).Instead,wearetheresultofourexperiences,includingsufferingandpain.Theproofthatessentialistdefinitionsofsufferingdonotholdisthattwocontradictoryanswerstotheproblemsofpainandsufferingcanbeequallyvalidandusefultomanagingthem:thestruggletodifferentiateoneselffromone’spain,suffering,orillness,andtheidentificationwithone’sownpain,sufferingorillness[11].OneofStonington’spatientssurprisedhimbysaying,“Iwanttobehereforthis,evenforthepain.Notreallybeingherewouldmakemesuffer”[43].Thepainofchildbirthhasbeenclaimedbywomenasanelementofself-constructionfortheirownidentitiesasmothersandwomeninthesensethattheywishtobetheonesincontrolofthetechnologyusedtoalleviatepain,andnottobecontrolledbysuchtechnology[19].Attitudeslikechoosingpainoracceptingsufferingcanbeawayofaffirmingtheself.ForViktorFrankl[44],acceptingunavoidablesufferingcanevenbeawayoffindingasenseinlife;sufferingandfacingsufferingbravelycanbeawayofaffirmingone’sownidentity,anachievement,anoblecause,insteadofadegradationoftheself.Sufferingcanintheendbeconsideredacharacteristicofone’sownidentity;aftersomuchsuffering,thepoetRosalíadeCastrofindsinherselfanemptyspacethatcannotbefilledwithanythingbutsuffering:“Thatatthebottom,theverybottom/ofmyinsides/thereisadesertwasteland/unfillablewithlaughter/orcontentment/butwiththebitter/fruitsofpain!”Footnote11[45].Itmaybepossibleto“feelathomeinsuffering”–notinamasochisticsense,butasawayofdealingwithit.Asanalternativetotheessentialdefinitions,Iproposetounderstandsufferingasanunpleasantorevenanguishingexperiencewhichcanseverelyaffectapersononapsychophysicalandevenexistentiallevel.ConceptualizingsufferingandpainConceptualizingsufferingasanexperienceemphasizesthefactthatitissomethingapersonexperiences(bothwhatDiltheycallsa“livedexperience”(Erlebnis),animmediate,unreflectedexperienceandan“ordinary,articulatedexperience”(Lebenserfahrung)[46,47].Weshouldnotlookatsufferingasanabstractphenomenon,butassomethingexperiencedbysomebody.Suffering,likepain,isunpleasantorevenanguishing:Evenifwedonotacceptanessentialistdefinitionandwerejecttheunderstandingofsufferingasa“lossoftheself”orasa“reaffirmationoftheself”,adefinitionisstillnecessary.“Unpleasantness”definessufferingandpain.LeknesandBastian[48]propose“tomovebeyondaviewofpainassimplyunpleasant”because“itcanalsobeexperiencedaspleasant,producepleasantexperiencesormotivateustowardspleasantexperiences”.Theyofferanumberofadvantagesandbenefitsofpain:itrepresentsapossibilityforredemptionafteratransgression,itcanhighlightbravery,motivateus,enhancesensation,offertemporaryrelieffromotherpainandoffer“aneffectivecontrasttomanynon-painfulexperiences,whichcanappearrelativelypleasantiftheyoccurafterpainhasended.”However,suchbenefitsoradvantagesexistonlybecausepainisunpleasant(ifitwerenot,itwouldnoserveasaredemption,etc).Theonlyconvincingargumentagainstthe“unpleasantness”ofpainisthe“painasymbolia”conditionwherepatientsfeelpainbutnotunpleasantness.AsIalreadymentioned,painconsistsofasomatosensorialperceptionfollowedbyatransitorymentalimageofthelocalchangeinthebody(nociception)ontheonehand,andanunpleasantemotionontheotherhand.ForLeknesandBastian,aconditionlike“painasymbolia”provesthatpainisnotnecessarilyunpleasant.However,Iarguethatpeoplesufferingfromsuchaconditiondonothaveacompleteexperienceofpain,butonlyofoneofitsparts.Inanycase,painasymboliaisamedicalconditionratherthanausualexperienceofpain.Footnote12 Sufferingisnotalwaysextreme.Sometimesitisabearable,short,inconsequentialexperience.However,itisimportanttoincludeinourdefinitionthepossibilitythatsufferingcanaffectusatanexistentialdimension,meaningthatitcanhaveanimpactoncrucialmattersregardingone’spersonallife,mattersthataffectourexistenceintheworld,likethedesiretocontinueliving,thedecisionofwhetherornottohavechildren,orevenhowtolivelife–choicesthathavetobeseeninthecontextofourattachmenttotheworld.Thispossibilityindeedcharacterizessufferingtooandhelpsustoperceiveits(possible)relevanceinlife.Moreover,theinclusionoftheexistentialdimensionofsufferingemphasizestheindividual’scapacityfordealingwiththeirunpleasantcircumstances/experiences,aswellasthecrucialimpactoftheirattitudeandchoicesonthewholeexperienceofsuffering.DiscussionNaturalisticandessentialconceptualizationsofpainandsufferingarenotadequatebecausetheycanhaveundesirableepistemological,ontologicalandmoralconsequences.Thenaturalisticapproachofclassicalevidence-basedmedicineincorporatesaparticularviewofhumanbeingsbasedontheCartesianmind/bodydichotomy,inwhichthebodyisunderstoodasamechanismthatworksaccordingtouniversalizeable,manipulableprocesses.Evenifthe“humanisticturn”inmedicinehasstartedtovindicatemoreholisticviewsofthehumanbeing,medicineanditsdisciplinesstilldependontheideathatthedifferentpartsofthebodycanbetreatedindependently.Moreover,symbolic,subjectiveandmeaningfuldimensionsofpainandsufferingarestillnotsufficientlytakenintoconsideration.Negativeepistemologicalandpracticalconsequencesofsuchanapproacharetheimpossibilityordifficultyofidentifyingandmanagingthesedimensionsofpainandsuffering,thefactthatunrecognizedpainandsufferingareinflictedtofurtherparticulargoals(healing,informationgain,prevention),aswellasthelackofconsiderationofconcretephenomenalikechronicpain,non-somaticpainortheplaceboeffect.Cassell’smedicalhumanismtriestorespondtotheseproblemsofclassicalevidence-basedmedicineandoffersagoodconceptualizationofpain,concurrentwiththeresultsofneurological,sociologicalandanthropologicalstudies.However,thisarticlecriticizesCassell’sdefinitionofsufferingbecause,despitethefactthatitisabletoovercomethemind/bodydualism,hisideaofpersonhoodisstillinadequate.Theideathatsufferingthreatenstheintegrityofapersonentailsanideaofthepersonasanautonomous,rational,coherentandwell-equilibratedhumanbeing–aviewwhichhasbeenrejectedbypsychological,philosophicalandsociologicaltheoriesinthetwentiethcentury–andanessentialdefinitionofsuffering.Cassell’sconceptionofthepersoncanalsonotbesustainedwiththehelpofnarrativetheoriesoftheself,becausethewayinwhichstoriesconcerntheconstructionofpersonalidentityandthewayinwhichtheyareincorporatedintoourunderstandingofourownlivesandthelivesofothersdonotsupportanideaofwholeness;rather,thestorieswetellourselvesarealwayspartial,fragmentaryandneverdefinitive.Moreover,thefactthatsufferingcancontributetothecreationofidentityinsteadofitsdestructioncontradictsCassell’sdefinition.Phenomenologyhascontributedto“embodyingthemind”and“mindingthebody”byemphasizingthecrucialroleofthebodyinourexperience,ascanbeseenintheexplanationoftheplaceboeffect,accordingtowhichthebodyisabletorespondmeaningfullytoademandingsituation(evenifwearenotconsciousofit).However,somephenomenologicaldefinitionsofsuffering(forexample,"sufferingasanalienationoftheself","sufferingasunhomelikebeingintheworld")maysuggestessentialanduniversalcharacteristicsofsuffering,thusexcludingfromitotherunpleasantoranguishingexperiencesthattheaffectedthemselvesindeedconsidersuffering.Amoreopendefinitionshouldbeabletoincorporatethesubjectivedimensionofsuffering,andeventhedifficultiesorimpossibilityofexpressingveryextremeexperiences,thefactthatapersonmaybesufferingwithoutknowingwhy,oreventhathe/shemaybepartiallyortotallyunawareofhis/hersuffering.Suchdimensionsofsufferingfollowfromthefactthathumanbeingshaveirrationalandincoherentdimensionswhicharenottransparenttothemselves.Apersonistheever-changingresultofhis/herdailystruggles,includinghis/hermanagementofsufferingandpain.Wehavetofocusnotonlyonwhatwe“lose”whenwesuffer,butalsoonthevariouscultural,personalandsocialadaptationsandresourcestomanagesuffering.ConclusionDefiningsufferingsubstantivelyturnsitintoanormativeconcept,whichresultsinepistemologicalmistakesandmoralinjustices.Notallsufferingisalienatinganditisunfairtodenythesufferingofothers;forinstance,thecategoricalaffirmationthatchildbirthpaindoesnotentailsuffering,asstatedbySvenaeus[24],canbeunfair.Atthesametime,notallaspectsofsufferingcanbeobjectified.Adefinitionofpaincannotbebasedonlyontheneurologicalunderstandingofit,buthastoincorporateotherrelevantfactorssuchascognitiveawareness,interpretation,behavioraldispositions,aswellasculturalandeducationalfactorsbeyondthemedicalsphere.Hence,aformal,non-essentialandnon-naturalisticconceptualizationofbothtermsisproposed.Sufferingisanunpleasantorevenanguishingexperiencewhichcanseverelyaffectapersononapsychophysicalandevenexistentiallevel.Likesuffering,painisalsounpleasant.Bothareexperienceswhichaffectthewholeperson(notmerelytheir“body”or“mind”),andacrucialaspectofthemisthepersonalattitudeandchoiceswhichareinturninfluencedbyculturalandsocialpatterns.Notonlythenaturalsciences,butalsothesocialsciencesandhumanitiesplayacrucialroleinunderstandingallthedimensionsofthesephenomena.Additionally,theviewofapersonasapsychophysicalinsteadofadualisticbeingdemandsatotalparadigmshiftinmedicineandnewresearchapproacheswhichareabletochallengetheboundariesofvariousdisciplines. Notes1.“Paintolerance”isdefinedas“themaximumintensityofapain-producingstimulusthatasubjectiswillingtoacceptinagivensituation”and“painthreshold”as“theminimumintensityofastimulusthatisperceivedaspainful”bytheInternationalAssociationfortheStudyofPain(http://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698#Nociception,consultedon10.02.2016).2.“MindingtheBody”isthetitleofapaperbyAntonioandHannahDamasio[49].3.ThehedonisticandmaterialisticEpicurusarguedinthefourthcenturyBCforthehumanbeingasanentirelymaterialentity.Althoughhedistinguishedbetweenthebody(sarx)andmind(psyché),hedidnotconsiderthemtobedifferentontologicalsubstances(asDescartesdid),arguingthattheyweresimplymadeupofdifferentkindsofatoms.ForEpicurus,sarxandpsychéaretwopartsofasingle,wholeorganism[50],andthemindcannotexistwithoutthebody.ThisdistinctionparallelstheEpicureandistinctionbetweenthe“painsofthebody”(ponos)andthe“sufferingsofthesoul”(lype).Theiroppositesareaponía(absenceofphysicalpain)andataraxía(absenceofspiritualsuffering).Totalhappiness(eudaimonía)ispossibleonlywhenweenjoybothaponíaandataraxía.4.Iusetheterm“disease”inthesenseofthemedicallydiagnosedpathology,leavingtheterm“illness”forthesubjectiveexperienceofthediseasebytheillperson[27].5.VanHooft[26]suggeststhatCassellmaintainssuchadistinction;however,thisisnotthecase[25].6.Notonlyphenomenologicaltheorieshavedevelopedalternativeconceptualizationsofthebody.SeeforexampleSchicktanz[51]onthedifferentconceptualizationsofembodimentinbioethicsandtheircorrespondinginterpretationsofautonomy.7.AccordingtoLeder[32],thebodyhasatendencyofself-concealment,ofperformingitsnormalprocessesandfunctionswithoutthembeing“present”forus(i.e.they–andthebodyingeneral–areessentially“absent”).However,whenwefeelpain,thebodyisnolonger“absent”;instead,itisvividlyperceived,“present”.8.Previousinterestinpsychogenicpaininthehistoryofmedicinehasbeenreported,atleastsincethesecondhalfofnineteenthcentury,asitcanbeseenintheworkofOttoBinswanger[15]9.ForKuhn,a“paradigmshift”occursduringascientificrevolution.Ascientificparadigmisdefinedasaconstellationoffactsandtheories(assumingthatthetheoriesarenotexactlydevelopedinordertoexplainpreviouslygivenfacts,butthatfactsemergetogetherwiththetheoriesexplainingthem).Inotherwords,ascientificparadigmincludesitsownscientificproblems,instrumentsandcriteriaforsolvingthem,awholeview(Gestalt)oftheworld.10.Mytranslation.11.Mytranslation.“¡Que.nofondobenfondo/dasentrañas/haiundesertopáramo/quenonseencheconrisas/nincontentos,/senónconfroitosdodolor/amargos!”12.Grahek[52]distinguishesbetweenpainasymboliaandothercircumstancesinwhichthepainfulstimulusseemstobefeltwithoutthesubsequentunpleasantemotion,likeforexamplelobotomized,cingulotomizedandmorphinizedpatients.Onlyinthecaseofpainasymboliadopersonsnotfellthepainfulstimuli.Theotherconditionsmayincludecasesofindifferencetothepainfulstimuli,butinordertobeindifferenttopain,oneneedstobeabletofeelit.References1.DamasioA.ElerrordeDescartes[Descartes´Error].Barcelona:EditorialCrítica.2006.2.BoeyinkDE.PainandSuffering.TheJournalofReligiousEthics.1974;2(1):85–98. 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Funding Thisarticleisapartialresultoftheresearchprojectentitled“TheExperienceofSuffering.FromtheMystic-AsceticChristianTraditiontotheTechno-ScientificApproach”,fundedbytheAustrianScienceFund(FWF;M2027-GBL). Availabilityofdataandmaterials Datasharingnotapplicabletothisarticleasnodatasetsweregeneratedoranalyzedduringthecurrentstudy. AuthorinformationAffiliationsDepartmentofPhilosophyandResearchCenterMedicalHumanities,UniversityofInnsbruck,Innrain52d,A6020,Innsbruck,AustriaNoeliaBueno-GómezAuthorsNoeliaBueno-GómezViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarContributionsNotapplicable.CorrespondingauthorCorrespondenceto NoeliaBueno-Gómez.Ethicsdeclarations Ethicsapprovalandconsenttoparticipate Thismanuscriptdoesnotreportdatacollectedfromhumansoranimals. Consentforpublication Notapplicable. Competinginterests Theauthordeclaresthatshehasnocompetinginterests. 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PhilosEthicsHumanitMed12,7(2017).https://doi.org/10.1186/s13010-017-0049-5DownloadcitationReceived:10November2016Accepted:13September2017Published:29September2017DOI:https://doi.org/10.1186/s13010-017-0049-5SharethisarticleAnyoneyousharethefollowinglinkwithwillbeabletoreadthiscontent:GetshareablelinkSorry,ashareablelinkisnotcurrentlyavailableforthisarticle.Copytoclipboard ProvidedbytheSpringerNatureSharedItcontent-sharinginitiative KeywordsPainSufferingMind-bodyproblemMedicinePhenomenology DownloadPDF Advertisement Philosophy,Ethics,andHumanitiesinMedicine ISSN:1747-5341 Contactus Submissionenquiries:AccesshereandclickContactUs Generalenquiries:[email protected]